Rapid Sequence Induction Strategies Among Critically Injured U.S. Military During the Afghanistan and Iraq Conflicts

Abstract

Introduction Rapid sequence intubation of patients experiencing traumatic hemorrhage represents a precarious phase of care, which can be marked by hemodynamic instability and pulseless arrest. Military combat trauma guidelines recommend reduced induction dose and early blood product resuscitation. Few studies have evaluated the role of induction dose and preintubation transfusion on hemodynamic outcomes. We compared rates of postintubation systolic blood pressure (SBP) of < 70 mm Hg, > 30% drop in SBP, pulseless arrest, and mortality at 24 hours and 30 days among patients who did and did not receive blood products before intubation and then examined if induction agent and dose influenced the same outcomes. Materials and Methods A retrospective analysis was performed of battle-injured personnel presenting to surgical care facilities in Iraq and Afghanistan between 2004 and 2018. Those who received blood transfusions, underwent intubation, and had an Injury Severity Score of ≥15 were included. Intubation for primary head, facial, or neck injury, burns, operative room intubations, or those with cardiopulmonary resuscitation in progress were excluded. Multivariable logistic regression was performed with unadjusted and adjusted odds ratios for the five study outcomes among patients who did and did not receive preintubation blood products. The same analysis was performed for patients who received full or excessive versus partial induction agent dose. Results A total of 153 patients had a mean age of 24.9 (SD 4.5), Injury Severity Score 29.7 (SD 11.2), heart rate 122.8 (SD 24), SBP 108.2 (SD 26.6). Eighty-one (53%) patients received preintubation blood products and had similar characteristics to those who did not receive transfusions. Adjusted multivariate analysis found odds ratios as follows: 30% SBP decrease 9.4 (95% CI 2.3-38.0), SBP < 70 13.0 (95% CI 3.3-51.6), pulseless arrest 18.5 (95% CI 1.2-279.3), 24-hour mortality 3.8 (95% CI 0.7-21.5), and 30-day mortality 1.3 (0.4-4.7). In analysis of induction agent choice and comparison of induction agent dose, no statistically significant benefit was seen. Conclusion Within the context of this historical cohort, the early use of blood products conferred a statistically significant benefit in reducing postintubation hypotension and pulseless arrest among combat trauma victims exposed to traumatic hemorrhage. Induction agent choice and dose did not significantly influence the hemodynamic or mortality outcomes.

Traumatic Cardiac Arrest—A Narrative Review

“…Furthermore, intubations in trauma patients are hampered by anatomical (e.g., facial trauma) and functional (e.g., rapid desaturation, sensitivity to anesthetics) patient-related factors, but also non-patient-related factors, such as crew resource management (CRM) aspects. Thus, intubation attempts in trauma patients may contribute to TCA [30].…”

Letter to the Editor: Swinging the pendulum in prehospital trauma mortality needs a more holistic approach

“…2 Furthermore, discussion is ongoing regarding appropriate amount of prehospital fluid and/or an optimal goal for fluid resuscitation among hypotensive trauma patients. 3 We should know the fact that interventions were more frequently performed when physicians are dispatched along with emergency medical service 4 and that on-scene stay was prolonged when more prehospital interventions were conducted. 5 Given that critically injured trauma patients in hemorrhagic shock should be rapidly delivered to surgical intervention by limiting scene time, we believe that a skill set of on-scene physicians should include the ability to decide not to perform any…”

“…As an example, attempting to intubate a patient physiologically challenged by hemorrhagic shock without achieving external hemorrhage control and/or volume resuscitation has been shown to contribute to postintubation hypotension, cardiopulmonary arrest, and increased mortality. 4 This is a lesson we have learned from both military experience and several publications in the civilian emergency medicine and critical care literature. From their reported data, the authors cannot delineate whether this may have been a contributing factor for at least some of their patients.…”